It’s that gut wrenching I-feel-like-I’m-riding-a-rollercoaster-but-I’m-really-at-my-desk feeling, heart racing like I’m walking a tightrope, sweating like I’m giving an antigun speech at an NRA convention but I’m just in a grocery store. Your body is in fight-or-flight mode and your mind is focused on either stemming the flood of adrenaline or getting the hell out of wherever you are. If any of this sounds familiar you may have had a panic attack. Read on I’ll define panic attacks, cover research on their prevalence, and explain the reason why physicians and not psychiatrists are more likely to diagnose this problem.

What is Panic?

To understand panic, you need to understand why primary care doctors and ER physicians (not psychologists and psychiatrists) diagnose most panic attacks. The experience of panic puts the body into an adrenaline overdrive – the heart beating so hard it feels like it’s going to burst, a shortness of breath that makes you feel on the verge of passing out, a stomach ache that could lead to vomiting. It not only feels awful; it feels like dying. Many first time panic sufferers rush to the ER to get checked out for a heart attack. After hours of testing and no evidence of heart attack, stroke, or other plausible problems, one culprit is left at the scene of the crime – a panic attack.

The symptoms of a panic attack according to the most widely used diagnostic guide (the DSM-V) are below:

Shortness of breath or hyperventilation

Heart palpitations or a racing heart

Chest pain or discomfort

Trembling or shaking

Choking feeling

Feeling unreal or detached from your surroundings

Sweating

Nausea or upset stomach

Feeling dizzy, light-headed, or faint

Numbness or tingling sensations

Hot or cold flashes

Fear of dying, losing control, or going crazy

To qualify for a panic attack, which isn’t a disorder (like panic disorder – I explain below), you need to at least four of these symptoms, they come to a peak in minutes, and the symptoms are distressing or extreme, for example, your shirt has a sweat streak up the back not just a little dampness under the armpits.

An Example Of Panic Attack

I once worked with a young woman who suffered from panic attacks that truly limited her life. A twinge of discomfort in her gut would send her running out of the store, abandoning a full shopping cart. If she didn’t escape the situation, she started to feel dizzy, short of breath, nauseated, and aching in her chest. When I saw her she had had scores of attacks and her experience was clearly panic disorder and not just isolated panic attacks.

What Is The Difference Between Panic Attacks and Panic disorder?

Just because you have a panic attack(s) doesn’t mean you suffer from panic disorder. This is an important distinction. Most people who have panic disorder can’t relax and go back to life as normal. Just one or a small number of panic attacks sets off a wave of anticipation and dread. They can’t go back to normal. They carry a sense of dread that they could really be in danger from the panic attack.

People who have panic disorder worry about the panic attacks and pass each moment dreading the next episode. In addition to worry, most panic survivors take some kind of steps to avoid the panic. They walk slowly to avoid overstimulating their heart; they don’t leave the house for fear that they won’t be able to get help if something were to happen (severe avoidance of public places is called agoraphobia); they avoid place that might make them feel trapped, like movie theaters (where they might have to climb over people to get to an exit if something went wrong); they may also avoid going out just because of embarrassment – “Mama, why is that man sitting on floor breathing so hard?”

Back to my patient discussed earlier. She was initially having many panic attacks but after a few years she had far fewer. She didn’t seem to worry about them as much but as I dug deeper, something became apparent. She lived a very structured and isolated life. She shopped when few people were around. She had to drive to stores in a particular order. Was she in control or living inside a nutshell?

She was adapting her life to her panic (one of the criteria for panic disorder listed above). She did have attacks but more so when something unexpected happened, e.g., she was shopping and there was a long line to checkout and no other registers.

She obsessively paid attention to physical sensations – another maladaptive coping strategy. The possibility of tension in her stomach kept her housebound for days but a brief window of comfort meant frantic trips to run as many errands and go as many places as possible. But if she felt the slightest discomfort she would stop what she was doing, race to her car, and drive home immediately.

She even plotted escape routes when she went into stores and restaurants, worried that if she had to leave she might get blocked in or unable to find the best way to the exit. As a result, she only went to familiar places and her husband was irritated that they rarely went out. Life was built around routines to control her panic and familiarity was her anti-anxiety prescription.

How Common Are Panic Attacks?

Many people experience panic attacks. A national survey of over 5,000 US citizens found that more than one quarter had at least one panic attack in their life time. That’s a lot of people, but my gut tells me that 25% is an underestimate. To meet the criteria in this study, you had to have at least 4 panic symptoms (from those listed above). So if you felt like you were having a heart attack and gasping for air but not two more symptoms, you wouldn’t meet criteria. This is what’s called a subclinical panic attack. But in most cases people who have one symptom tend to have others but not always.

Most people have had some kind of panic-like symptoms to a lesser degree. Public speaking evokes terror in most people and many people report a panic attack or darn close to it when put on the spot. Many people have may have experienced a lesser form of panic, what is sometimes called an anxiety attack, which isn’t as intense as a panic attack. These attacks can be upsetting but not as debilitating as a panic attack. The person doesn’t obsess about them afterwards or ever feel their health was in any physical danger.

Another Strange Aspect of the DSM’s Panic Disorder

So you have multiple panic attacks that meet full criteria and you worry about them for more than one month. There’s one question left and it is the most important – is the panic attack expected or unexpected? True panic disorder occurs when someone has a panic attack that is uncued. That is, the panic attack is out of the blue and not caused by a certain situation, like public speaking, seeing a dog, or a being in a car accident and then having to drive again. Uncued panic attacks feel unpredictable and random.

I find this criteria a bit strange because most panic attacks become less and less random and more and more predictable by the person. Over time, most people can go from feeling that the attacks are random to being predictable. When the attacks first start, a person doesn’t know what is happening they are very likely to experience the attacks as random. With more time and insight people can pick up on causes and triggers, especially if they go to therapy or they read books about the condition. Soon they learn that the panic attacks are anything but random and this is part of the cure. But I’m not a strong believer in the medical diagnosis of panic attacks, this is the Diagnostic and Statistics Manual, the so called Bible of mental health diagnoses.

Other Conditions With Panic Attacks

Outside of panic disorder, panic attacks occur in a number of mental health problems. If panic occurs in social situations then you it may have social anxiety disorder. Going out into public and feeling that people are looking at you, judging, or criticizing you might trigger a panic attack in some. The attacks may be cued in some stressful situations but not others. But not everyone with social anxiety has it result in a panic attack.

Trauma is another source of panic. I work with combat veterans and often they have panic attacks when going into public places. For most, these symptoms clearly started after a deployment to a combat zone. There panic can be connected to the either a specific experience during combat or more likely just being in a hostile country for months on end and being subjected to possible or actual life threatening situations. After this exposure, many vets have an understandable cautiousness about being in crowds when they return home. Panic attacks in public places are the most common complaints I hear from vet. However, the diagnosis is PTSD and not panic disorder because the panic attacks are caused by traumas.

People who have phobias sometimes also have panic attacks. The sight of a spider to some people is more anxiety provoking than a gun pointed to the head. My grandmother had a terrible fear of snakes and I remember being yelled at for surprising her with one of my plastic toy snakes. I never did that again. Specific phobias are much more isolated and the panic attacks are connected to a particular feared object or situation (e.g., animals, needles, heights, etc.)

When you factor all the ways that panic can occur (panic disorder, social anxiety, PTSD, specific phobias), it’s no surprise that over 25% of people will at some point have a full blown panic attack. Panic attacks are more severe than just general stress or anxiety attacks. They can feel like dying. Remember that panic disorder the attacks appear random (at least at first). Whatever the cause of panic and whatever your diagnosis, understanding it and know that it is a common experience is crucial. You’re not alone in this experience and there are many things that can be done to improve the condition and help you cope and ever overcome this challenge.